Monday, September 28, 2015

I have noted in the past that I receive a steady stream of email from physicians asking about their eligibility for board certification in the clinical informatics subspecialty. I have created several posts that allow me to point them to a general answer, the most recent one of which was last year. My most prominent advice has always been for those who can get certified to do so prior to the end of the “grandfathering” period if they can.

I have also voiced my concerns about the whole process. This is not because I believe that board certification in clinical informatics is not a good thing. I do believe it provides an excellent professional recognition of the work physicians do in informatics.

But the process is problematic on several fronts. First, by choosing to have clinical informatics as a subspecialty of all specialties, we require all who are certified to maintain a primary medical specialty. Given that most medical specialties now have time-limited certifications, this can create a challenging situation for those who work predominantly in informatics. It also rules out certification for those who do not have a primary medical specialty, either because their certification lapsed, or they never pursued it in the first place. I know of plenty of highly capable physician-informaticians who are not eligible for board certification.

A second major problem concerns the title of this posting, which is what will happen in 2018. According to current rules, the grandfathering period will end at this time, and the only pathway to board certification will be a two-year on-site Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship. While such a fellowship (such as the one we have launched at Oregon Health & Science University) will serve as excellent training for a career in clinical informatics, I am not convinced it should be the only pathway by which one can become board-eligible. This is especially the case for the significant numbers of physicians who gravitate into informatics well into their careers and way beyond the end of their formal training. For a physician who has established a career and/or a family, it is unimaginable that he or she could give that up to return to the salary, relocation, and time commitment of a fellowship. This is also inconsistent with work in the 21st century, where professionals, especially in knowledge fields like medicine and informatics, transition to new career activities along the way. Requiring a two-year, on-the-ground experience to become a clinical informatics professional is a relic of 20th-century approaches to training, where you did all of your education before jumping into the workforce, never to return for more.

Our online graduate program at OHSU has shown there are other pathways to successful careers in clinical informatics. We have a track record of many of our physician graduates being hired into clinical informatics positions, including the coveted Chief Medical Informatics Officer (CMIO) role. We have had about 40 graduates successfully pass the board exam, and I am not aware of a single person who failed it. We have also demonstrated that online educational programs can not only provide knowledge, but also practical real-world experiences.

The problem of after 2018 is illustrated explicitly by three “case studies,” two of individuals who have emailed and another who is a current student in an educational program. Let’s look at their cases.

The first emailed to me, “I am planning to take the exam to become board certified. I have a valid medical license, recently matched into an internal medicine residency. I hold a master’s degree in biomedical informatics, and have experience in clinical informatics. I have a senior colleague who recently graduated from an internal medicine residency. He is planning to apply for the clinical informatics board exam, but the application requires that we should have at least three years of experience, which could not be practically possible given the hectic residency schedule.” This individual has more informatics training and experience than his senior colleague, who will be able to become certified during the grandfathering period, but he himself will come up against 2018.

The second emailed to me, “I am a current second-year resident in internal Medicine and I was hoping to get some advice regarding my path in clinical informatics. When I graduate from residency in June of 2017, I had planned on working as a hospitalist while completing OHSU’s online masters in clinical informatics. My anticipated date of completion for which would be June of 2019. I had hoped to sit for the clinical informatics board certification at that time. Unfortunately because of my family, I will not be living in a city that I would be able to participate in one of the in-person fellowship programs. … If I am not eligible for grand-fathering, how important do you think it would be to be board-certified in clinical informatics vs. holding a master’s?”

The final individual is currently in an MD/PhD program. She will finish her dual degrees next year, in 2016. But she then will need to complete a residency in some specialty, which will end well after 2018. Despite having a PhD in biomedical informatics, this individual will not be eligible to sit for the board exam under the current rules.

I worry that the success of the clinical informatics subspecialty will be compromised by the post-2018 requirement of an ACGME-accredited fellowship. Clearly these fellowships are one of many possible pathways to obtain excellent training in clinical informatics. But having the fellowship be the only pathway to board certification may prohibit many highly capable physicians from achieving their full potential in clinical informatics. I do hope that more enlightened leaders within the American Board of Preventive Medicine (ABPM), ACGME, and other organizations will recognize these problems and provide additional pathways for physicians to train and become successful in clinical informatics.